what is history of health education

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In This Article Expand or collapse the "in this article" section Health Education

Introduction, definition and scope of practice.

Historical and Philosophical Foundations
Theories and Models
Community Assessment
Implementation and Best Practices
Relationship to Health Professions, Health-Enhancing Systems, and Sectors
Health Communication, Social Marketing, and Policy Advocacy
Professionalism and Ethics

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Housing as a Determinant of Health
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Health Education by Elaine Auld , Stephen F. Gambescia LAST REVIEWED: 23 February 2011 LAST MODIFIED: 23 February 2011 DOI: 10.1093/obo/9780199756797-0044

Health education is defined as “any combination of learning experiences designed to facilitate voluntary actions conducive to health” ( Green and Kreuter 2005 ). Although the history of health education dates back to the 19th century, it was not until the 1940s that the field began evolving as a distinct discipline. Over time, health education’s theory and practice base have broadened from focusing on one-to-one and mass media behavioral interventions to encompass responsibility for policies, systems, and environments that affect population health. In the early 21st century, the terms health education and health promotion (i.e., the latter including an ecological approach) are often used interchangeably in the United States, while internationally health promotion is used as an overarching concept that includes health education. Health education is considered a mature profession given that it has developed a discrete body of knowledge, defined competencies, a certification system for individuals, a code of ethics, a federal occupational classification, and recognized accreditation processes in higher education. Health education is generally aligned with the behavioral and social sciences as one of the core dimensions of public health study and practice. Additionally, the field draws from theories and models from education, health studies, communications, and other diverse areas. The unique combination of these knowledge areas forms the basis for health education competencies. Health educators employ a core set of competencies, regardless of the diverse practice settings in which they work (i.e., schools, universities, health departments, community-based organizations, health-care settings, worksites, and international organizations). This bibliography is organized around major areas of health education practice, such as assessing, planning, implementing, managing, and evaluating health education or health promotion programs, services, and interventions. It includes historical and philosophical foundations, and development of its professionalism and ethics. The discipline embraces both qualitative and quantitative methods, community-based participatory research, health communication and social marketing principles, and policy and media advocacy to accomplish program objectives. Health educators are stalwarts in the fight for social justice and believe that the health of a population should be a priority in any society.

The definition and scope of health education have evolved since the 1950s, particularly in relation to improved understanding of behavioral and socio-ecological influences on health. The early definition of health education in Griffiths 1972 primarily emphasized the provision of learning experiences to promote voluntary changes to individual health. Subsequent work in Robertson and Minkler 1994 , Schwartz, et al. 1995 , and Downie, et al. 1996 provides a broader context of health education in relation to policy, systems, and environmental changes inherent in the practice of health promotion and related philosophies. Taub, et al. 2009 provides a concise overview of how the terms health education and health promotion are used differently in the early 21st century in the United States versus internationally, due to historical, cultural, and political considerations. Gold and Miner 2002 and Modeste, et al. 2004 provide good sources of contemporary definitions for many other terms, which is especially important due to the eclectic base from which health education draws.

Downie, Robert, Carol Tannahill, and Andrew Tannahill. 1996. Health promotion: Models and values . 2d ed. Oxford: Oxford Univ. Press.

A comprehensive and systematic review of how to define health promotion and the range of underlying values held by those in practice. One of the few works that addresses the influence of values held by the profession, government entities, and communities on health promotion.

Gold, Robert S., and Kathleen R. Miner. 2002. 2000 Joint Committee on Health Education and Promotion Terminology. Journal of School Health 7.2: 3–7.

DOI: 10.1111/j.1746-1561.2002.tb06501.x

The Joint Committee convenes every decade to evaluate the current terminology in health education, which changes with the advancement of scholarship, technological developments, and professional practice. This citation is the seventh major health education terminology report issued during the past seventy years.

Griffiths, William. 1972. Health education definitions, problems, and philosophies. Health Education Monographs 31:12–14.

This health education pioneer defines health education as an “attempt to close the gap between what is known about optimum health practice and that which is actually practiced.” Later, as part of the views offered to President Richard M. Nixon’s First White House Conference on Health Education, Griffiths also asserted the health educator’s role in changing societal conditions that influence health.

Modeste, Naomi, Teri Tamayose, and Helen H. Marshak. 2004. Dictionary of public health promotion and education: Terms and concepts . 2d ed. San Francisco: Jossey-Bass.

Brief dictionary of the most common and more esoteric terms used in health promotion and education. Expands on concepts beyond a rote definition, which is useful to both students and practitioners.

Robertson, A., and Meredith Minkler. 1994. New health promotion movement: A critical examination. Health Education Quarterly 21:295–312.

Explores the various meanings of health education to date and identifies the characteristics of a new health promotion movement and implications for practice and research.

Schwartz, Randy, Robert Goodman, and Alan Steckler. 1995. Policy advocacy interventions for health promotion and education: Advancing the state of practice. Health Education Quarterly 22.4: 421–426.

This theme issue outlines the role of policy advocacy in achieving health education and health promotion objectives. Includes seminal articles on environmental and policy change for tobacco, cardiovascular disease, physical activity, and nutrition.

Taub, Alyson, John P. Allegrante, Margaret P. Barry, and Keiko Sakagami. 2009. Perspectives on terminology and conceptual and professional issues in health education and health promotion credentialing. Health Education & Behavior 36.3: 439–450.

DOI: 10.1177/1090198109333826

Explains how the terms health education and health promotion have been defined and used differently in the United States and other countries, and includes a succinct and useful table. Also addresses key international perspectives on professional competencies, standards, and accreditation.

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Public Health Education: Sources, Growth and Operational Philosophy

Affiliation.

1 Professor Emeritus, School of Public Health, University of California, Berkeley.
PMID: 26657784
DOI: 10.1177/0272684X15619090

An historical overview of public health education: its sources, development and operational philosophy, the contributions of many disciplines, particularly social science, and key individuals such as Lewin are traced through the past half century. The emergence of health education as a "helping profession" and the expansion of its focus to broader "marketplaces" of change are highlighted. The state of the art today is reviewed and the functions of health educators described with emphasis on "obtaining people's participation" in programs to bring about change. Problems still existing, particularly professional training, are addressed.

Keywords: Operational Philosophy; people's participation; public health education.

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What is Public Health Education and Why is it Important? What History Can Tell Us

Kiegan Baranski graduated with the Washington University Class of 2020.

During times of relative well-being, the educational efforts of public health officials go largely unnoticed and typically blend in to our everyday lives as vaccine requirements and hygiene protocols. But every so often, major global events like the current COVID-19 pandemic make failures in our health education system startlingly apparent. Amidst a daily rush of new information from public health officials urging us to adopt better health-safety practices, we unfortunately see equal amounts of misinformation and confusion. In times like these, we’re left to wonder: If the American public had been given a stronger education in health fundamentals, would we have been better prepared to see through the misinformation and support a more unified response in our defense against COVID?

With the gracious help of Professor Corinna Treitel and WashU’s own medical humanities minor, my independent research on Bruno Gebhard and the birth of the American health museum provides insights about the importance of public health education and its history.

In the 1930s, the American Public Health Association (APHA) noticed a similarly startling lack of health fundamentals in the American public and responded by testing out a new educational model at the 1939 New York World’s Fair: the health museum, which had seen great success in Europe (particularly Germany). Following the success of Germany’s Dresden Health Museum, the APHA hired its lead curator, Dr. Bruno Gebhard, to set up an interactive exhibit called The Hall of Man . Here, visitors could see detailed models of the human body showcased in massive, eye-catching displays with lights, sound and even on-site nurses trained to answer health-related questions. With 11.5 million visitors over the course of the 1939-40 World’s Fair, The Hall of Man exceeded the APHA’s expectations and created a name for the health museum model in American public health education.

Only one year later, Gebhard opened the Cleveland Health Museum (CHM), the shining example of what the American health museum model could be. Funded primarily by community donations until its closure in 2006, the CHM would prove to be a valuable educational institution, which inspired (and even directly aided) the creation of several other similar museums.

So, what exactly made the health museum model so successful, and what did this mean for health education as a whole? Whereas pre-existing medical museums often showcased cabinets of gruesome specimens locked behind “DO NOT TOUCH” signs and large blocks of jargon-filled text, this new health museum model catered directly to the public by using artistic design principles to appeal to general audiences’ sense of wonder. For example, the process of pregnancy and birth were a particularly myth-shrouded mystery for many Americans in the early-mid 1900s, as frequent questions to the CHM’s physician Q&A panel demonstrated. Take this one, for example: “I am pregnant. Should I have my teeth pulled?”

The CHM produced and distributed a now-famous set of 24 sculptures depicting the inner processes of fetal development, called the “Birth Series” (or the “Dickinson-Belskie models”). As you can see below, the models combined the aesthetic appeal of classical fine arts with anatomical accuracy in a plaster-cast medium that encouraged visitors to touch them. This emphasis on interaction had the added benefit of accessibility, as demonstrated by the models’ use by institutions such as a Washington school for the blind in 1945, which reported that the models allowed its blind students an entirely new depth of understanding that standard textbooks and verbal explanations could never provide.

Although the health museum model has since wavered in popularity, it proved the educational effectiveness of appealing directly to the public’s innate curiosity through visual, interactive displays. As Gebhard said himself , the key to teaching the public about their own health isn’t through coercion or threat, but instead “leading people to be at ease physically and mentally.” Instead of belittling and patronizing the uninformed, the most effective health education was found through the exhibits that invited the audience to become captains of their own learning.

Unfortunately, public health education is a largely unexplored topic among historians of medicine. However, looking into the past can give us insights about the importance and lasting impact of health education and its strategies in our modern world.

If you’d like to learn more, you can read Kiegan’s full research paper here .

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Health Education and Health Promotion: Key Concepts and Exemplary Evidence to Support Them

First Online: 09 October 2018

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Hein de Vries 8 ,
Stef P. J. Kremers 8 &
Sonia Lippke 9

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Health is regarded as the result of an interaction between individual and environmental factors. While health education is the process of educating people about health and how they can influence their health, health promotion targets not only people but also their environments. Promoting health behavior can take place at the micro level (the personal level), the meso level (the organizational level, including e.g. families, schools and worksites) and at the macro level (the (inter)national level, including e.g. governments). Health education is one of the methods used in health promotion, with health promotion extending beyond just health education.

Models and theories that focus on understanding health and health behavior are of key importance for health education and health promotion. Different classes of models and theories can be distinguished, such as planning models, behavioral change models, and diffusion models. Within these models different topics and factors are relevant, ranging from health literacy, attitudes, social influences, self-efficacy, planning, and stages of change to evaluation, implementation, stakeholder involvement, and policy changes. Exemplary health promotion settings are schools, worksites, and healthcare, but also the domains that are involved with policy development. Main health promotion methods can involve a variety of different methods and approaches, such as counseling, brochures, eHealth, stakeholder involvement, consensus meetings, community ownership, panel discussions, and policy development. Because health education and health promotion should be theory- and evidence-based, personalized interventions are recommended to take empirical findings and proven theoretical assumptions into account.

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de Vries, H., Kremers, S.P.J., Lippke, S. (2018). Health Education and Health Promotion: Key Concepts and Exemplary Evidence to Support Them. In: Fisher, E., et al. Principles and Concepts of Behavioral Medicine. Springer, New York, NY. https://doi.org/10.1007/978-0-387-93826-4_17

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Health and education

Education has the power to transform the lives of children and young people, and the world around them. At UNESCO, inclusive and transformative education starts with healthy, happy and safe learners. Because children and young people who receive a good quality education are more likely to be healthy, and likewise those who are healthy are better able to learn and complete their education.

Guided by the UNESCO Strategy on education for health and well-being , UNESCO works to improve the physical and mental health, well-being and education outcomes of all learners. By reducing health-related barriers to learning, such as gender-based violence, gender inequality, HIV and sexually transmitted infections (STIs), early and unintended pregnancy, bullying and discrimination, and malnutrition, UNESCO, governments and school systems empower learners to understand their rights, learn better and lead fulfilling lives.

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Health promotion

“Health promotion is the process of enabling people to increase control over, and to improve their health.” Health Promotion Glossary, 1998

A brief history of Health Promotion

The first International Conference on Health Promotion was held in Ottawa in 1986, and was primarily a response to growing expectations for a new public health movement around the world. It launched a series of actions among international organizations, national governments and local communities to achieve the goal of "Health For All" by the year 2000 and beyond. The basic strategies for health promotion identified in the Ottawa Charter were: advocate (to boost the factors which encourage health), enable (allowing all people to achieve health equity) and mediate (through collaboration across all sectors).

Since then, the WHO Global Health Promotion Conferences have established and developed the global principles and action areas for health promotion. Most recently, the 9th global conference (Shanghai 2016), titled ‘Promoting health in the Sustainable Development Goals: Health for all and all for health’, highlighted the critical links between promoting health and the 2030 Agenda for Sustainable Development. Whilst calling for bold political interventions to accelerate country action on the SDGs, the Shanghai Declaration provides a framework through which governments can utilize the transformational potential of health promotion.

Promoting Healthier Populations

The Sustainable Development Goals (SDGs) provides a bold and ambitious agenda for the future. WHO is committed to helping the world meet the SDGs by championing health across all the goals. WHO’s core mission is to promote health, alongside keeping the world safe and serving the vulnerable. Beyond fighting disease, we will work to ensure healthy lives and promote well-being for all at all ages, leaving no-one behind.

Our target is 1 billion more people enjoying better health and well-being by 2023.

Good Governance

Strengthen governance and policies to make healthy choices accessible and affordable to all, and create sustainable systems that make whole-of-society collaboration real. This approach is based on the rationale that health is determined by multiple factors outside the direct control of the health sector (e.g. education, income, and individual living conditions) and that decisions made in other sectors can affect the health of individuals and shape patterns of disease distribution and mortality.

Health Literacy

Improving health literacy in populations provides the foundation on which citizens are enabled to play an active role in improving their own health, engage successfully with community action for health, and push governments to meet their responsibilities in addressing health and health equity.

Healthy Settings

The settings approach has roots in the WHO Health for All strategy and, more specifically, the Ottawa Charter for Health Promotion. Healthy Settings key principles include community participation, partnership, empowerment and equity. The Healthy Cities programme is the best-known example of a successful Healthy Settings programme.

Social mobilization

Bringing together all societal and personal influences to raise awareness of and demand for health care, assist in the delivery of resources and services, and cultivate sustainable individual and community involvement.

What is health promotion?
Initiative on urban governance for health and well-being
Achieving well-being: a draft global framework for integrating well-being into public health utilizing a health promotion approach (WHA 76/A76/7 Add.2)
Well-being and health promotion (WHA75.19)
Contributing to social and economic development: sustainable action across sectors to improve health and health equity (WHA 67)
Reducing health inequities through action on the social determinants of health (WHA 62.14)
Contributing to social and economic development: sustainable action across sectors to improve health and health equity (follow-up of the 8th Global Conference on Health Promotion) (EB134)
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Defining a Comprehensive School Health Program: An Interim Statement.

Hardcopy Version at National Academies Press

2 The Evolution of School Health Programs

Historical overview of school health 6.

Numerous public health initiatives, reports, studies, organizations, and professional societies have promoted the development of school health since the colonial American era. In fact, Benjamin Franklin advocated a “healthful situation” and promoted physical exercise as one of the primary subjects in the schools that were developing during his time. However, prior to the mid-1800s, efforts to introduce health into the schools were isolated and sparse. It was not until 1840 that Rhode Island passed the first legislation to make health education mandatory, and other states soon adopted this concept.

In 1850, the Sanitary Commission of Massachusetts, headed by Lemuel Shattuck, produced a report that has become a classic in the field of public health and had a significant influence on school health. Shattuck served as a teacher in Detroit and member of the school committee in Concord, Massachusetts, where he helped reorganize the public school system of the town. This background led to school programs receiving major attention as a means to promote public health and prevent disease. The report states that good health is the basis for wealth, happiness, and long life and that all children should be taught that preserving their health and the health of others is one of their most important duties. Knowledge leads to good health, while ignorance leads to poor health and disease.

Between the late 1800s and 1950, many social concerns and public health issues focused on the role of schools in promoting and maintaining health. In the 1890s, schools in Boston and Philadelphia were early pioneers in establishing cooperative programs with philanthropic organizations to provide school lunches to fight malnutrition. The era of “medical inspection” in schools started at the end of the nineteenth century in response to problems of urbanization and immigration. In 1894, 50 “medical visitors” were appointed in Boston to visit schools and examine children thought to be “ailing.” By 1897, Chicago, Philadelphia, and New York had all started comparable programs, and most of the participating medical personnel provided their services without compensation. The success of these early programs developed into more formalized medical inspection. In 1899, Connecticut made examination of school children for visual defects compulsory. In 1902, New York City provided for the routine inspection of all students to detect contagious eye and skin diseases and employed school nurses to help their families seek and follow through with treatment. In 1906, Massachusetts made medical inspection compulsory in all public schools and this ushered in broad-based programs of medical inspections in which school nurses and physicians participated. By 1911, there were 102 cities employing cadres of school nurses. In 1913, New York City alone had 176 school nurses. A great deal of the nurses' time was spent in home visits to families with children who had been excluded from school because of illness or infection, encouraging these families to have their children treated and returned to school. During this period the prevalence of tuberculosis in the United States also had a dramatic impact on school health with the development and spread of “open-air classrooms” in all major cities under the supervision of both medical and educational personnel.

One of the most influential groups in the development of school health was the Joint Committee on Health Problems and Education, which was jointly sponsored by the American Medical Association (AMA) and the National Education Association (NEA). Prior to 1920, the committee published the report Minimum Health Requirements for Rural Schools. Their 1927 paper Health Supervision and Medical Inspection of Schools strongly promoted the emerging concept of coordination among the medical services, the physical education, and the health education programs in schools.

Early in the 1920s, the AMA/NEA Joint Committee on Health Problems and Education reported the results of a nationwide survey on the status of health education in 341 city schools. The findings are particularly interesting in light of the current U.S. Public Health Service's Healthy People 2000, which calls for an “increase to at least 75 percent the proportion of the nation's elementary and secondary schools that provide planned and sequential kindergarten through grade 12 quality school health education” (U.S. Department of Health and Human Services, 1990). In the 1920s, over 73 percent of the surveyed schools taught health directly under the name of “health” or “hygiene.” Correlating content in their health curriculum to other subjects such as language, civics, reading, physical education, general science, and art was reported by 108 cities. Daily inspection for health habits was reported by 69 percent of the 341 cities and nearly 30 percent reported having organized student health clubs for the promotion of health in the elementary schools.

School health became the focus of a variety of organizations during the 1930s. The May 1938 issue of the Journal of Educational Sociology was exclusively devoted to the subject under the theme “Health Education.” At the end of the decade, the Educational Policies Commission of the NEA issued a report, Social Services and the Schools. The report dealt with administrative guidelines for health examination, medical attention, communicable disease control, mental health, health instruction, the healthful environment and regimen, and health supervision of teachers and employees.

The focus on school health continued throughout the next several decades. In 1940, the U.S. Public Health Service published a 100-page pamphlet titled High Schools and Sex Education. In 1940, the Eighteenth Yearbook of the American Association of School Administrators was titled Safety Education. In 1942, the Twentieth Yearbook was Health in Schools. When many World War II draftees were found to suffer from nutritional deficiencies, the school was considered the place to focus on a solution; the National School Lunch Act was passed in 1946 to provide federal funds and surplus agricultural commodities to assist local schools in providing a nutritious hot lunch to school children. In 1950, the Twenty-Ninth Yearbook of the Department of Elementary School Principals of the NEA was titled Health in the Elementary School. The February 1960 issue of The National Elementary Principal also featured elementary school health programs including health services, health instruction, and health administration. The AMA/NEA Joint Committee on Health Problems in Education issued three editions of a publication titled Health Appraisal of School Children. This booklet established “standards for determining the health status of school children, through the cooperation of parents, teachers, physicians, nurses, dentists, and others.”

The most significant school health education initiative of the 1960s was the School Health Education Study (SHES). This study defined health as a dynamic, multidimensional entity and outlined 10 conceptual areas of focus that over the years have often been translated into 10 instructional content areas. These conceptual areas include such themes as human growth and development, personal health practices, accidents and disease, food and nutrition, mood-altering substances, and the role of the family in fulfilling health needs. The primary publication from this initiative was titled School Health Education Study: A Summary Report, which provided the basis for most of the current legislation on school health education (Sliepcevich, 1964). Numerous additional publications resulted from nearly 10 years of this activity, including curriculum designs and teacher–student resource guides addressing the 10 instructional content areas of health education across all grade levels.

Several important school health services initiatives also took place in the 1960s, including the U.S. Public Health Service's study of school health services and the Title I provision of the Elementary and Secondary Education Act, which tripled the number of school nurses. Another significant event was the development of the school nurse practitioner role in the late 1960s. At this time, issues of diagnosis and treatment in nontraditional health facilities surfaced, and the prevailing belief was that such activities were not permissible by any primary care provider, including physicians in the school. However, by 1972, a state-by-state survey sponsored by the Robert Wood Johnson Foundation failed to uncover any legislation that would prohibit the delivery of these services in schools, and working in close collaboration with physicians, the clinical functions of school nurses were expanded to include primary care services. The introduction of school nurse practitioners into schools resulted in reaching students in need of primary care, an increase in problem resolution rates, and greater accuracy in excluding students from school for illness and injury (Hilmar and McAtee, 1973; Kohn, 1979; Silver et al., 1976).

During the twentieth century, several White House conferences have been convened that relate directly to school health issues. One of the most important was the White House Conference on Children and Youth, which had a session in December 1970 on children under age 13 and a session in February 1971 on young people over age 13. Each of the landmark conferences resulted in specific recommendations and suggested programs related to school health services, health instruction, and a healthy school environment.

Many additional developments in school health have taken place in recent years. Examples include: the establishment and funding of school health initiatives through the Centers for Disease Control and Prevention; the creation of a Federal Interagency Committee on School Health, chaired by the assistant secretaries of health and of elementary and secondary education, and a National Coordinating Committee on School Health; and the Robert Wood Johnson Foundation school-based clinic initiative, which catalyzed the rapid proliferation of school-based clinics.

The committee will revisit some of these historical developments in its full report in order to understand the lessons learned and the bases for current programs. However, it is clear from this brief overview that for many decades, health and education professionals have joined together to establish, implement, and evaluate school health programs in response to societal needs. The history of these school health programs provides perspective and a valuable resource of information for understanding current programs and for designing and improving programs in the future.

THE COMPREHENSIVE SCHOOL HEALTH PROGRAM

Today, school health has evolved into what is termed a comprehensive school health program (CSHP). The committee believes that the general goal of a CSHP is to establish a system of home, school, and community support to assure that students are provided with a planned sequential program of study, appropriate services, and a nurturing environment that promotes the development of healthy, well-educated, productive citizens.

At this preliminary stage, the committee has proposed a set of optimal outcomes for CSHPs—a vision of what these programs ought to be and what they might be able to do. The feasibility of these outcomes and possible strategies for achieving them will be examined in the committee's full report. The optimal outcomes can be categorized into three general areas:

student outcomes,

programmatic and organizational outcomes, and

community outcomes.

Student Outcomes

Students will assume personal responsibility for avoiding social, emotional, and physical health-compromising behaviors and for engaging in health-promoting behaviors. Students' health needs—preventative, emergency, acute, and chronic—will be addressed to allow students to reach the highest possible level of educational achievement and personal health. Particular attention will be given to the health component of Individual Education Plans of students with special health care needs who require special education and related services.

Programmatic and Organizational Outcomes

The relationship between health status and educational achievement will be evident in the policies and programs of the school. The school's health emphasis will be integrated across all activities. Linkages among program components, disciplines, and participating agencies will be clearly defined and regularly evaluated. Individual and group health problems will be identified and managed with appropriate prevention, assessment, intervention or referral, and follow-up measures. Services will be organized to provide appropriate and timely responses to emergency, acute, and chronic health problems. The school's education and health programs will be continually reexamined and reformed as necessary to enhance student health, performance, and achievement.

Community Outcomes

The community will be actively involved in determining the design of a school health program and in supporting and reinforcing the goals of the program. This design will include assurance that schools are safe, with an environment conducive to learning and health promotion, and that policies and procedures are in place to enhance the use of schools as a community resource for health. All health-related programs delivered by the school and by community members through the schools will enhance the health status of the students and result in an improvement of the health and quality of life of the community.

PREVIOUS DEFINITIONS AND MODELS OF SCHOOL HEALTH PROGRAMS

The Three-Component Model

The three-component model is considered the traditional model of school health programs. Originating in the early 1900s and evolving through the 1980s, this model defines a school health program as consisting of the following three basic components:

Health instruction is accomplished through a comprehensive health education curriculum that focuses on increasing student understanding of health principles and modifying health-related behaviors.

Health services includes prevention and early identification and remediation of student health problems.

A healthful environment is concerned with the physical and the psychosocial setting and such issues as safety, nutrition, food service, and a positive learning atmosphere.

The Eight-Component Model

In the 1980s, the three-component model was expanded to include additional components (Kolbe, 1986; Allensworth and Kolbe, 1987). According to this model, a comprehensive school health program contains the following eight essential components:

Health education consists of a planned, sequential, K–12 curriculum that addresses the physical, mental, emotional, and social dimensions of health.

Physical education is a planned, sequential, K–12 curriculum promoting physical fitness and activities that all students could enjoy and pursue throughout their lives.

Health services focuses on prevention and early intervention, including the provision of emergency care, primary care, access and referral to community health services, and management of chronic health conditions. Services are provided to students as individuals and in groups.

Nutrition services provides access to a variety of nutritious and appealing meals, an environment that promotes healthful food choices, and support for nutrition instruction in the classroom and cafeteria.

Health promotion for staff provides health assessments, education, and fitness activities for faculty and staff, and encourages their greater commitment to promoting students' health by becoming positive role models.

Counseling, psychological, and social services include school-based interventions and referrals to community providers.

Healthy school environment addresses both the physical and psychosocial climate of the school.

Parent and community involvement engages a wide range of resources and support to enhance the health and well-being of students.

The Division of Adolescent and School Health of the Centers for Disease Control and Prevention has promoted the eight-component model, and it has received widespread attention and adoption by many states in recent years.

Joint Committee on Health Education Terminology

In 1990, the Association for the Advancement of Health Education convened a committee of delegates from the Coalition of National Health Organizations 7 and the American Academy of Pediatrics. The charge to this Joint Committee on Health Education Terminology was to review and update earlier terminology and to provide definitions for new terms currently used in the health education field. The Joint Committee defined a CSHP as follows (Joint Committee on Health Education Terminology, 1991):

A comprehensive school health program is an organized set of policies, procedures, and activities designed to protect and promote the health and well-being of students and staff which has traditionally included health services, healthful school environment, and health education. It should also include, but not be limited to, guidance and counseling, physical education, food service, social work, psychological services, and employee health promotion.

Related Models and Definitions

In recent years, additional models, definitions and descriptions have emerged that build upon previous models. Several examples are discussed below.

Nader (1990) has proposed that the school is one locus of a broad range of health and educational activities, carried out by a diverse group of health and educational personnel based both in the community and in the school. The model emphasizes that the school, community, and family/friends are the three important systems supporting children's health status and educational achievement. Further, the media—including educational, electronic, and print media—play a prominent role as part of the community system in influencing health-related behaviors. According to this model, the first steps in developing a CSHP are to establish community linkages and carry out a community needs and resources assessment. These steps will then lead to the implementation and expansion of school health services, school health education, and a healthful school environment.
— Focuses on priority behaviors that interfere with learning and long-term well-being.
— Fosters the development of a supportive foundation of family, friends, and community.
— Coordinates multiple programs within the school and community.
— Uses interdisciplinary and interagency teams to coordinate the program.
— Uses multiple intervention strategies to attain programmatic goals.
— Promotes active student involvement·
— Solicits active family involvement.
— Provides staff development.
— Accomplishes health promotional goals via a program planning process.

management,

health promotion and education,

school health services,

healthy and safe environment,

integration of school and community programs, and

specialized services for students with special needs.

The distinguishing characteristics of this model include the importance of the management role in coordinating and integrating the other critical elements, and the emphasis on students with special health care needs.

International models often include the school health program as an element of a country's primary health care system (Wallace, et al., 1992). Although each country's approach to primary health care may vary, school programs throughout the world typically include components of preventive, promotive, curative, and rehabilitative services. Another prominent feature in many countries is the strong collaboration between the school nurse and physician, with both health professionals often available to the school, either on a full- or part-time basis.

Full-Service Schools

Previous definitions and models have culminated in the full-service schools model (Dryfoos, 1994). A full-service school is the center for collocating a wide range of health, mental health, social, and/or family services into a one-stop, seamless institution. The exact nature and configuration of services and resources offered will vary from place to place, but services should thoroughly address the unique needs of each particular school and community—hence the title “full-service schools.”

According to this model, a full-service school provides a quality education for students that includes individualized instruction, team teaching, cooperative learning, a healthy school climate, alternatives to tracking, parental involvement, and effective discipline. The school and/or community agencies provide comprehensive health education, health promotion, social skills training, and preparation for the world of work.

A distinguishing feature of this model is the broad spectrum of services to be provided at the school site by community agencies. Some examples of these various services include:

Health services: health and dental screening, nutrition, and weight management.
Mental health services: individual counseling, crisis intervention, and substance abuse treatment and follow-up.
Family welfare and social services: family planning; child care; parent literacy; employment training; legal services; basic services for housing, food, and clothing; and recreation and cultural activities.

The preceding discussion of definitions and models is not intended to be exhaustive. Other worthy definitions and models may exist, and any exclusion from this discussion is not intended to minimize their importance. Instead, the purpose of the preceding discussion is to illustrate the diversity of definitions that exist and to emphasize that as these models and definitions have evolved, they tend to become more complex and appear to demand more from the schools and community.

Much of the information in this synopsis has been excerpted from the book entitled, Historical Perspectives on School Health, by Richard Means, Ed.D. (Means, 1975). The reader is encouraged to refer to this source book for a more complete understanding of the history of school health in the United States prior to 1975.

Members of the Coalition are: American Public Health Association, School Health Education and Services Section and the Public Health Education and Health Promotion Section; American College Health Association; American School Health Association; Association for the Advancement of Health Education; American Alliance for Health, Physical Education, Recreation and Dance; Association of State and Territorial Directors of Public Health Education; Society for Public Health Education, Inc.; and the Society of State Directors of Health, Physical Education and Recreation.

Cite this Page Institute of Medicine (US) Committee on Comprehensive School Health Programs; Allensworth D, Wyche J, Lawson E, et al., editors. Defining a Comprehensive School Health Program: An Interim Statement. Washington (DC): National Academies Press (US); 1995. 2, The Evolution of School Health Programs.

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Characteristics of an Effective Health Education Curriculum

Today’s state-of-the-art health education curricula reflect the growing body of research that emphasizes:

Teaching functional health information (essential knowledge).
Shaping personal values and beliefs that support healthy behaviors.
Shaping group norms that value a healthy lifestyle.
Developing the essential health skills necessary to adopt, practice, and maintain health-enhancing behaviors.

Less effective curricula often overemphasize teaching scientific facts and increasing student knowledge. An effective health education curriculum has the following characteristics, according to reviews of effective programs and curricula and experts in the field of health education 1-14 :

An effective curriculum has clear health-related goals and behavioral outcomes that are directly related to these goals. Instructional strategies and learning experiences are directly related to the behavioral outcomes.

An effective curriculum has instructional strategies and learning experiences built on theoretical approaches (for example, social cognitive theory and social inoculation theory) that have effectively influenced health-related behaviors among youth. The most promising curriculum goes beyond the cognitive level and addresses health determinants, social factors, attitudes, values, norms, and skills that influence specific health-related behaviors.

An effective curriculum fosters attitudes, values, and beliefs that support positive health behaviors. It provides instructional strategies and learning experiences that motivate students to critically examine personal perspectives, thoughtfully consider new arguments that support health-promoting attitudes and values, and generate positive perceptions about protective behaviors and negative perceptions about risk behaviors.

An effective curriculum provides instructional strategies and learning experiences to help students accurately assess the level of risk-taking behavior among their peers (for example, how many of their peers use illegal drugs), correct misperceptions of peer and social norms, emphasizes the value of good health, and reinforces health-enhancing attitudes and beliefs.

An effective curriculum provides opportunities for students to validate positive health-promoting beliefs, intentions, and behaviors. It provides opportunities for students to assess their vulnerability to health problems, actual risk of engaging in harmful health behaviors, and exposure to unhealthy situations.

An effective curriculum provides opportunities for students to analyze personal and social pressures to engage in risky behaviors, such as media influence, peer pressure, and social barriers.

An effective curriculum builds essential skills — including communication, refusal, assessing accuracy of information, decision-making, planning and goal-setting, self-control, and self-management — that enable students to build their personal confidence, deal with social pressures, and avoid or reduce risk behaviors.

For each skill, students are guided through a series of developmental steps:

Discussing the importance of the skill, its relevance, and relationship to other learned skills.
Presenting steps for developing the skill.
Modeling the skill.
Practicing and rehearsing the skill using real–life scenarios.
Providing feedback and reinforcement.

An effective curriculum provides accurate, reliable, and credible information for usable purposes so students can assess risk, clarify attitudes and beliefs, correct misperceptions about social norms, identify ways to avoid or minimize risky situations, examine internal and external influences, make behaviorally relevant decisions, and build personal and social competence. A curriculum that provides information for the sole purpose of improving knowledge of factual information will not change behavior.

An effective curriculum includes instructional strategies and learning experiences that are student-centered, interactive, and experiential (for example, group discussions, cooperative learning, problem solving, role playing, and peer-led activities). Learning experiences correspond with students’ cognitive and emotional development, help them personalize information, and maintain their interest and motivation while accommodating diverse capabilities and learning styles. Instructional strategies and learning experiences include methods for

Addressing key health-related concepts.
Encouraging creative expression.
Sharing personal thoughts, feelings, and opinions.
Thoughtfully considering new arguments.
Developing critical thinking skills.

An effective curriculum addresses students’ needs, interests, concerns, developmental and emotional maturity levels, experiences, and current knowledge and skill levels. Learning is relevant and applicable to students’ daily lives. Concepts and skills are covered in a logical sequence.

An effective curriculum has materials that are free of culturally biased information but includes information, activities, and examples that are inclusive of diverse cultures and lifestyles (such as gender, race, ethnicity, religion, age, physical/mental ability, appearance, and sexual orientation). Strategies promote values, attitudes, and behaviors that acknowledge the cultural diversity of students; optimize relevance to students from multiple cultures in the school community; strengthen students’ skills necessary to engage in intercultural interactions; and build on the cultural resources of families and communities.

An effective curriculum provides enough time to promote understanding of key health concepts and practice skills. Behavior change requires an intensive and sustained effort. A short-term or “one shot” curriculum, delivered for a few hours at one grade level, is generally insufficient to support the adoption and maintenance of healthy behaviors.

An effective curriculum builds on previously learned concepts and skills and provides opportunities to reinforce health-promoting skills across health topics and grade levels. This can include incorporating more than one practice application of a skill, adding “skill booster” sessions at subsequent grade levels, or integrating skill application opportunities in other academic areas. A curriculum that addresses age-appropriate determinants of behavior across grade levels and reinforces and builds on learning is more likely to achieve longer-lasting results.

An effective curriculum links students to other influential persons who affirm and reinforce health–promoting norms, attitudes, values, beliefs, and behaviors. Instructional strategies build on protective factors that promote healthy behaviors and enable students to avoid or reduce health risk behaviors by engaging peers, parents, families, and other positive adult role models in student learning.

An effective curriculum is implemented by teachers who have a personal interest in promoting positive health behaviors, believe in what they are teaching, are knowledgeable about the curriculum content, and are comfortable and skilled in implementing expected instructional strategies. Ongoing professional development and training is critical for helping teachers implement a new curriculum or implement strategies that require new skills in teaching or assessment.

Botvin GJ, Botvin EM, Ruchlin H. School-Based Approaches to Drug Abuse Prevention: Evidence for Effectiveness and Suggestions for Determining Cost-Effectiveness [pdf 85K] -->. In: Bukoski WJ, editor. Cost-Benefit/Cost-Effectiveness Research of Drug Abuse Prevention: Implications for Programming and Policy . NIDA Research Monograph, Washington, DC: U.S. Department of Health and Human Services, 1998;176:59–82.
Contento I, Balch GI, Bronner YL. Nutrition education for school-aged children. Journal of Nutrition Education 1995;27(6):298–311.
Eisen M, Pallitto C, Bradner C, Bolshun N. Teen Risk-Taking: Promising Prevention Programs and Approaches --> . Washington, DC: Urban Institute; 2000.
Gottfredson DC. School-Based Crime Prevention. In: Sherman LW, Gottfredson D, MacKenzie D, Eck J, Reuter P, Bushway S, editors. Preventing Crime: What Works, What Doesn’t, What’s Promising [pdf 100K] -->. National Institute of Justice; 1998.
Kirby D. Emerging Answers: Research Findings on Programs to Reduce Teen Pregnancy . Washington, DC: National Campaign to Prevent Teen Pregnancy; 2001.
Kirby D, Coyle K, Alton F, Rolleri L, Robin L. Reducing Adolescent Sexual Risk: A Theoretical Guide for Developing and Adapting Curriculum-Based Programs . Scotts Valley, CA: ETR Associates; 2011.
Lohrmann DK, Wooley SF. Comprehensive School Health Education. In: Marx E, Wooley S, Northrop D, editors. Health Is Academic: A Guide to Coordinated School Health Programs . New York: Teachers College Press; 1998:43–45.
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Nation M, Crusto C, Wandersman A, Kumpfer KL, Seybolt D, Morrissey-Kane, E, Davino K. What works: principles of effective prevention programs. American Psychologist 2003;58(6/7):449–456.
Stone EJ, McKenzie TL, Welk GJ, Booth ML. Effects of physical activity interventions in youth. Review and synthesis. American Journal of Preventive Medicine 1998;15(4):298–315.
Sussman, S. Risk factors for and prevention of tobacco use. Review. Pediatric Blood and Cancer 2005;44:614–619.
Tobler NS, Stratton HH. Effectiveness of school-based drug prevention programs: a meta-analysis of the research. Journal of Primary Prevention 1997;18(1):71–128.
U.S. Department of Health and Human Services. Preventing Tobacco Use Among Young People–An Update: A Report of the Surgeon General. Atlanta (GA): U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2011: 6-22–6-45.
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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century (2003)

Chapter: 2. history and current status of public health education in the united states, 2 history and current status of public health education in the united states.

This section discusses two broad phases of public health education in America. 1 The first phase, during which independent schools of public health were first created, occurred between roughly 1914 and 1939 and was privately funded by philanthropies. The second phase, which overlapped slightly with the first, was marked by federal and state funding, and encompasses the years 1935 to the present. Following this brief historical overview, we discuss the current status of public health education in the United States.

Public Health Education: 1914–1939

By the end of the 19th century medical schools had proliferated. There were also many schools of nursing, established by hospitals to provide a source of well-trained labor. However, there was no distinct education or career pattern for public health officers; most were practicing physicians who were called upon to assist with epidemic diseases in times of crisis. It was in this context that staff of the Rockefeller Sanitary Commission attempted to enlist public health officers in the southern United States to

Material in the History section of this chapter is abstracted from the commissioned paper prepared for the committee by Elizabeth Fee, Ph.D. The paper appears in its entirety in .

aid in a campaign to eradicate hookworm. They found little interest in or dedication to public health, leading Wickliffe Rose, the architect and organizer of the commission, to believe that a new profession was needed, composed of men and women who would devote their entire careers to controlling disease and promoting health at a population level. Three possible approaches for public health education were debated—the engineering or environmental, the sociopolitical, and the biomedical.

Rose enlisted Abraham Flexner in the move to establish education for a separate public health career. On October 16, 1914, Flexner brought together 11 public health representatives and 9 Rockefeller trustees and officers for a meeting. It was decided that there were essentially three categories of public health officers: those with executive authority such as city and state health commissioners; the technical experts in specific fields such as bacteriologists, statisticians, and engineers; and the field workers such as local health officials, factory and food inspectors, and public health nurses.

Rose laid out ideas for a system of public health education centered on a university affiliated, research intensive, scientific school, separate from a medical school, whose graduates would be strategically placed throughout the United States. This central scientific school of public health would be linked to a network of state schools that sent extension agents into the field, and emphasized not only public health education, short courses and extension courses to upgrade the skills of health officers in the field, but also demonstrations of best practices. The plan as implemented, however, focused on research and largely ignored public health practice, administration, public health nursing, and health education. The biomedical side of public health was emphasized to the exclusion of its social and economic context and no attention was given to the political sciences or to the need to plan for social or economic reforms.

The Johns Hopkins University School of Hygiene and Public Health became the first endowed school of public health, opening during the influenza epidemic of 1918. Later, Rockefeller Foundation officials agreed to provide funding for additional schools of public health including ones at Harvard and Toronto. These first schools were well-endowed private institutions that favored persons with medical degrees, had curricula that leaned heavily toward the laboratory sciences, and emphasized infectious diseases. Because the Rockefeller Foundation gave fellowships to medical graduates around the world the schools tended to have an international flavor. Programs of field training were not emphasized. By 1930 these first schools were graduating a small number of individuals with sophisticated scientific education but they were not producing the needed large numbers of public health officers, nurses, and sanitarians.

Public Health Education: 1935 to the Present

Passage of the Social Security Act of 1935 provided a major stimulus to the further development of public health education. Provisions of this act increased funding for the Public Health Service and provided federal grants to the states to assist them in developing their public health services. Federal law now required each state to establish minimal qualifications for health personnel employed using federal assistance, and recommended at least one year of graduate education at an approved school of public health. For the first time, the federal government provided funds, administered through the states, for public health training. Overall, the states budgeted for more than 1,500 public health trainees, and the existing training programs were soon filled to capacity. As a result of the growing demand for public health credentials, several state universities began new schools or divisions of public health and existing schools of public health expanded their enrollments.

In 1936, 10 schools offered public health degrees or certificates requiring at least one year of residence: Johns Hopkins, Harvard, Columbia, Michigan, California at Berkeley, Massachusetts Institute of Technology, Minnesota, Pennsylvania, Wayne State, and Yale (Committee on Professional Education, 1937). By 1938 more than 4,000 people (1,000 of whom were physicians) had received some public health training with funds provided by the federal government through the states. Increased funding and the continuing need for additional public health graduates led many colleges and universities to open public health departments and establish programs offering training courses of a few months’ or even a few weeks’ duration. Federal training funds were allotted to California, Michigan, Minnesota, Vanderbilt, and North Carolina to develop short courses for the rapid training of public health personnel.

The tremendous push in the late 1930s toward training larger numbers of public health practitioners was also a push toward practical training programs rather than research. Public health departments wanted personnel with one year of public health education: typically, the masters of public health (M.P.H.) generalist degree. If they could not attract public health practitioners holding this credential, they settled for a person with a few months of public health training. Ideally, they also wanted persons who understood practical public health issues rather than scientific specialists with research degrees. Thus, public health education in the 1930s tended to be practically oriented, with considerable emphasis on fields such as public health administration, health education, public health nursing, vital statistics, venereal disease control, and community health services. During this period, too, many schools developed field training programs in local communities where their students could obtain experience

in the practical world of public health and prepare for roles within local health departments. The 1930s were thus the prime years of community-based public health education.

The growth of short training programs in public health education continued throughout the war years to meet the demand for physicians, nurses, and sanitarians with at least minimal training in tropical diseases, parasitology, venereal disease control, environmental sanitation, and a variety of infectious diseases. For the burgeoning industrial production areas at home, industrial hygiene was in demand; for areas with military encampments, sanitary engineering and malaria control were urgent concerns.

Schools of public health and public health training programs revamped their educational programs to meet these needs and turned out large numbers of health professionals with a smattering of specialized education in high-priority fields. The research-oriented schools of public health, such as Hopkins and Harvard, maintained their research programs largely by recruiting foreign students—many from Latin America—to staff their laboratory and field programs.

Deans of schools of public health were concerned about the rapid growth of public health education programs and in 1941 organized the Association of Schools of Public Health (ASPH) to promote and improve graduate education for public health professionals. In 1946 the Committee on Professional Education of the American Public Health Association began monitoring the standards of public health education amid complaints that profit-making public health training courses of questionable quality were offering public health degrees by correspondence from faculty who did not even know of their appointment (Shepard, 1948). Demand for minimum adequate standards was increasing. However, a 1950 survey of schools of public health found major difficulties here, too. These schools were overcrowded and under-funded, and lacked key faculty members, classroom and laboratory space, and necessary equipment (Rosenfeld et al., 1953). Under pressure to provide more practical experience, the Deans argued that they needed a 70 percent increase in full-time faculty to expand the applied fields of instruction; they further believed they could double the number of enrolled students if necessary financial support was forthcoming (Rosenfeld et al., 1953).

Given the high demand for public health graduates and the need for schools and programs to train them, it is not surprising that the criteria for accreditation of schools of public health as implemented at mid-century were relatively undemanding by current standards. To become accredited, schools were required to have at least eight full-time professors as well as lecture rooms, seminar rooms, and adequate laboratory facilities; and were to be located close to local public health services that could be used for “observation and criticism.” Additionally, these public health

services had to be of sufficiently high quality “to make observation fruitful” (Winslow, 1953).

For a few years following World War II the concepts of social medicine, social epidemiology, and the ecology of health achieved prominence. New courses were developed that emphasized the social and economic context of health problems. Schools of public health instituted classes that focused on world population and the food supply; the impact of industry and transportation on health; the impact of cultural, social, and economic forces on health; evaluation of health status; and public health as a community service (Winslow, 1953). At Pittsburgh, Thomas Parran had decided that the curriculum should be organized around “the systematic presentation of illustrative topics which deal with the interrelation of man and his total environment and with the political, economic, and social framework within which the health officer must work” (Blockstein, 1977). Yale’s core course on “Principles and Practice of Public Health” was similarly organized around a series of interdisciplinary seminars running throughout the academic year. Winslow commented approvingly that the eleven schools of public health constituted “eleven experimental laboratories in which new pedagogic approaches are constantly being devised” (Winslow, 1953).

The overall impression of the accredited schools of public health in 1950 was that they were doing a good job of preparing public health practitioners through courses and fieldwork, that the numbers of faculty and students were growing, and that curricular and research innovations seemed promising. The main complaints of the schools seemed to be lack of funding to pay faculty, expand space, and purchase equipment.

While schools of public health were concerned about a lack of money, major funding was financing the construction of community hospitals through the Hill-Burton Program, and the National Institutes of Health (NIH) was experiencing rapid growth in research funding. The institutes expanded with enormous increases in financial resources, transferring most of their funds to universities and medical schools in the form of research grants. Grants were awarded based on the decisions of peer review committees composed of non-federal experts in the relevant fields of research. Liberals, conservatives, medical school deans, and researchers were all happy with the system, and members of Congress were pleased to bankroll such a popular and uncontroversial program (Strickland, 1972; Ginzberg and Dutka, 1989).

In this environment schools of public health had to compete with medical schools for research grants in a system dominated by powerful medical school professors. The historic core funders of schools of public health (the major foundations) were turning their interest to building departments of preventive medicine and community medicine within medical schools. Further, increasing political conservatism and the

McCarthy era were having a negative impact on views about public health.

To survive, schools of public health turned to research funding to pay the salaries of additional faculty members, using the rationale that new faculty could spend some of their time teaching and some of their time on funded research. As this strategy was implemented, the following pattern emerged. If a particular department within a school was devoted mainly to teaching or to public health practice, the numbers of faculty stayed stable or gradually declined. If the department was devoted to research, and was reasonably successful at funding that research, the department grew, sometimes at an impressive rate. Even deans who strongly favored teaching and field training over research became unable to resist the pressures that encouraged research over practical training. Available funding, and faculty who were suited by education, experience, and personality to succeed in the research system, shaped the schools of public health and drove their priorities.

Because the system of research funding was not oriented toward field research, public health practice, public health administration, the social sciences, history, politics, law, anthropology, or economics, the laboratory sciences tended to thrive while the practice and other non-quantitative disciplines suffered. The community-based orientation of the 1930s disappeared, and the field training programs virtually ceased to exist.

As faculty withdrew into their laboratories, they further distanced themselves from the problems of the local health departments, which were experiencing increasing difficulty. Federal grants-in-aid to the states for public health programs steadily declined during the 1950s as the total dollar amounts fell from $45 million in 1950 to $33 million in 1959. Given inflation, this represented a dramatic decline in purchasing power (Terris, 1959). Lacking funds, health departments could not afford new people or initiate new programs. Health departments ran underfunded programs with underqualified people who answered to unresponsive bureaucrats.

Between 1947 and 1957 the number of students educated in schools of public health fell by half. Alarmed, Ernest Stebbins of Johns Hopkins and Hugh Leavell of Harvard, representing ASPH, urged Congress to support public health education. They found an especially sympathetic audience in Senator Lister Hill and Representative George M. Rhodes, and in 1958, Congress enacted a two-year emergency program authorizing $1 million a year in federal grants to be divided among the accredited schools of public health.

The First National Conference on Public Health Training in 1958 noted that these funds had provided 1,000 traineeships and had greatly improved morale in public health agencies. The conference further requested appropriations for teaching grants and construction costs for teaching facilities, and urged that faculty salary support be provided for teaching.

Its report concluded with a stirring appeal to value public health education as vital to national defense:

D’ day for disease and death is everyday. The battle line is in our own community. To hold that battle line we must daily depend on specially trained physicians, nurses, biochemists, public health engineers, and other specialists properly organized for the normal protection of the homes, the schools, and the work places of some unidentified city somewhere in America. That city has, today, neither the personnel nor the resources of knowledge necessary to protect it (U.S. DHEW, 1958).

President Dwight Eisenhower signed the Hill-Rhodes Bill, authorizing $1 million annually in formula grants for accredited schools of public health and $2 million annually for five years for project training grants; between 1957 and 1963 the United States Congress appropriated $15 million to support public health trainees. The downward trend in public health enrollments was halted. Between 1960 and 1965 the total number of applicants to schools of public health more than doubled; the number of faculty members increased by 50 percent; the average space occupied increased by 50 percent; and the average income of the schools more than doubled (Fee and Rosenkrantz, 1991).

Following the passage of Medicare and Medicaid legislation in 1965, state health agencies turned to schools of public health to provide the scientific basis for rational decision-making in health services delivery and training for medical care administrators and financial managers. ASPH estimated that 6,220 new positions in medical care administration required graduate-level education (ASPH, 1966). The U.S. Public Health Service provided quick funding to schools of public health to provide short courses in health services administration.

The 1960s brought major progress for the civil rights movement and for President Lyndon B. Johnson’s War on Poverty which included the Office of Equal Opportunity (OEO). The OEO helped create 100 neighborhood health centers and the Department of Health, Education, and Welfare (DHEW) supported another 50. A strong environmental movement developed following the publication of Rachel Carson’s Silent Spring in 1962. In 1970 Earth Day attracted 20 million Americans in demonstrations against assaults on nature; by 1990 Earth Day brought out 200 million participants in 140 countries (McNeil, 2000). The Environmental Protection Agency (EPA) was created and the first Clean Air Act was passed in 1970. Also created during this period were the Occupational Safety and Health Administration (OSHA) and the National Institute of Occupational Safety and Health (NIOSH).

Throughout the 1960s and early 1970s, schools of public health thrived with federal funding available for both teaching programs and research.

In 1960 there were 12 accredited schools of public health in the United States, 8 were added between 1965 and 1975. Between 1965 and 1972, student enrollments again doubled, with the large majority being candidates for the master of public health (M.P.H.) degree. The trend to admit more students who were not physicians, and more students without prior experience in public health continued. In 1946, 61 percent of all students admitted to schools of public health for the M.P.H. were physicians; by 1968–1969 that figure had dropped to only 19 percent of M.P.H. candidates (Hall, 1973).

Along with the growth in the accredited schools of public health came a rapid growth in other forms of public health and health services education. Graduate programs were established in a variety of university departments and schools (e.g., engineering, medicine, nursing, business, social work, education, and communication) offering degrees in such fields as environmental health, health management and administration, nutrition, public health nursing, and health education. Universities were creating popular baccalaureate programs in health administration, environmental engineering, health education, and nutrition. By mid-1970, some 69,000 students were enrolled in various allied health programs (Sheps, 1976). Although 5,000 graduate degrees in public health were awarded each year, approximately half of higher education for public health was occurring outside of accredited schools of public health.

Then, in 1973, President Richard M. Nixon recommended terminating federal support for schools of public health and discontinuing all research training grants, direct traineeships, and fellowships. J. Thomas Grayston of the University of Washington reflected the thoughts of the field when he said:

the greatest immediate challenge to the School of Public Health and Community Medicine is the uncertainty of federal funding brought about by the administration’s announced intention to end, or greatly curtail, federal support for the training of public health manpower, coupled with a similar proposal to decrease support for research training (Grayston, 1974).

The threatened elimination of funding was averted, however, and in 1976 Congress passed the Health Professions Educational Assistance Act (P.L. 94-484), which provided for a number of programs in health professions education. The trend, however, was toward ever more reliance on targeted research funding. Also in 1976 the Milbank Memorial Fund issued its extensive report, Higher Education for Public Health , proposing a new structure for the public health educational system—a three tiered structure.

First, schools of public health were to educate people to assume leadership positions. Next, programs in graduate schools would prepare the large

number of professionals engaged in providing clearly differentiated specialty services, for example, public health nurses, health educators, and environmental health specialists. Finally baccalaureate programs could provide some of the “trained entry-level personnel” (MMF, 1976). The report identified three core areas of public health on which the schools should focus: epidemiology and biostatistics, social policy and the history and philosophy of public health, and management and organization for public health. In addition, the report recommended that schools should serve as regional resources by helping faculties in medical and other health-related schools to develop teaching programs and research in public health; they should become involved in the operation of community health services; and schools should design their research within a broad framework established by the needs of public health practice.

The report had little impact. Under President Ronald Reagan the pressures intensified. Between 1980 and 1987, spending for health professions’ education by the Department of Health and Human Services (DHHS) Bureau of Health Professions declined annually by more than 50 percent from a high of $411,469,000 in 1980 to $189,353,000 in 1987. General purpose traineeship grants to schools of public health dropped from $6,842,000 in 1980 to $2,958,000 in 1987. Project grants for graduate training in public health were funded at $4,949,000 in 1980, but dropped to zero funding in 1982 and remained unfunded through 1987. Curriculum development grants, funded at $7,456,000 in 1980, were not funded at all in 1981 and 1982, but then recovered with funding at $1,740,000 in 1983, then at $2,856,000 in 1984 rising to $9,787,000 in 1987. Grants for graduate programs in health administration were funded at $2,967,000 in 1980, dropped to $726,000 in 1981, and then rose to $1,416,000 in 1982 where funding remained fairly steady, with 1987 levels at $1,482,000 (U.S. DHHS, 1988).

Funding has continued to be problematic for public health education programs and schools of public health. Through the 1990s funding levels remained nearly constant. During that time tuition and other costs continued to increase, resulting in a reduction in the amount of public health professional education actually provided. At the beginning of the 21st century we find a major barrier to workforce development is the “incredibly weak” budget allocated for training (Gebbie, 1999; PHLS, 1999).

Following the events of September 11, 2001, there has been new interest in public health and promises of increased funding. If used wisely, these promised funds will strengthen the public health system through investments in both needed technologies and properly educated and prepared public health professionals. To better understand the future needs of public health education, it is important to examine its current status. The following pages provide a brief overview of public health education in the United States, examine schools of public health in greater detail,

and describe progress made since the landmark report The Future of Public Health (IOM, 1988).

CURRENT STATUS

Many college graduates who work in public health are educated in other disciplines. For example, of the total public health workforce, nurses make up about 10.9 percent and physicians comprise about 1.3 percent (Center for Health Policy, 2000). The HRSA list of categories of public health occupations includes administrators, professionals, technicians, protective services, paraprofessionals, administrative support, skilled craft workers, and service/maintenance workers. Within these categories fall a number of different kinds of positions (see Appendix E for complete list) including administrative/business professional, public health dental worker, public health veterinarian/animal control specialist, environmental engineering technician, and community outreach/field worker.

Within public health education, the basic public health degree is the M.P.H., while the doctor of public health (Dr.P.H.) is offered for advanced training in public health leadership. There are also individuals working in public health who receive academic degrees (e.g., M.S. and Ph.D.) in public health disciplines such as epidemiology, the biological sciences, biostatistics, environmental health, health services and administration, nutrition, and the social and behavioral sciences. The public health workforce also includes many professionals trained in disciplines such as social work, pharmacy, dentistry, and health and public administration.

Most persons who receive formal education in public health are graduates of one of the 32 accredited schools of public health or of one of the 45 accredited M.P.H. programs. The Council on Education for Public Health (CEPH) is responsible for adopting and applying the criteria that constitute the basis for an accreditation evaluation. In 1998–1999 there were 5,568 graduates from the then 29 accredited schools of public health (ASPH, 2000). The majority of these graduates (61.5 percent) earned an M.P.H. degree, an additional 28.4 percent received a masters degree in some other discipline, and 10.1 percent earned doctoral degrees (ASPH, 2000). According to a survey conducted by Davis and Dandoy (2001), the 45 accredited programs in Community Health and Preventive Medicine (CHPM) and in Community Health Education (CHE) graduate between 700 and 800 master’s degree students each year.

There are other programs in which students receive master’s level training in public health. These include programs in public administration and affairs, health administration, and M.P.H. programs in schools of medicine. In 1997–1998 an unknown number of the 9,947 graduates of masters degree programs in public administration and affairs (M.P.A.) emphasized public health in their training (NASPAA, 2002). The Association of University

Programs in Health Administration report that in 2000 there were 1,778 graduates who received masters degrees, with some (again an unknown number) of them the M.P.H. and M.S. degrees (AUPHA, 2000). In 1998 of the 125 accredited U.S. medical schools, 36 medical schools offered a combined M.D./M.P.H. degree, and 56 reported that they taught separate required courses on such topics as public health, epidemiology, and biostatistics (Anderson, 1999). Public health workers also may receive undergraduate training from colleges or universities that offer programs in the environmental sciences or in health education and health promotion.

While it is unclear exactly how many public health workers there are in the United States today, it is estimated that about 450,000 people are employed in salaried positions in public health, and an additional 2,850,000 volunteer their services (Center for Health Policy, 2000). This is probably an undercount, according to the Center for Health Policy (2000), because states reporting the number of workers within their jurisdiction almost never include information about public health workers found in non-governmental and community partner agencies. Additionally, limited information is obtained regarding the numbers of volunteers and salaried staff in voluntary agencies. Persons who graduate with training in public health are, however, only a small portion of the public health workforce. Nationally, it has been estimated that 80 percent of public health workers lack specific public health training (CDC, 2001c) and only 22 percent of chief executives of local health departments have graduate degrees in public health (Turnock, 2001).

Schools of Public Health

Schools of public health vary in many ways including size, organization, and degrees offered All schools offer courses in the five areas identified as core to public health: biostatistics, epidemiology, environmental health sciences, health services administration, and social and behavioral sciences. The extent and breadth of offerings within these categories varies, however. In addition, schools offer courses in a number of other areas including nutrition, biomedical and laboratory sciences, disease control, genetics, and much more (please see Appendix A ).

Progress in Schools of Public Health

In 1988 the Institute of Medicine (IOM) report, The Future of Public Health, described the field of public health as being in disarray (IOM, 1988). The focus of that report was on public health practice but it did have a number of recommendations for schools of public health. These recommendations called for

new linkages between public health schools and programs, and public health agencies at the federal, state, and local levels;

the development of new training opportunities for professionals who are already practicing in public health;

development of new relationships within universities between public health schools and programs and other professional schools and departments;

the conduct of a wide range of research that includes basic and applied research and research on program evaluation and implementation;

more extensive approaches to education that encompass the full scope of public health practice; and

strengthening the knowledge base in the areas of international health and the health of minority groups.

The report also urged schools of public health to serve as resources to government at all levels in the development of public health policy. In summary, the task defined by the IOM report was “to assist the schools in developing a greater emphasis on public health practice and to equip them to train personnel with the breadth of knowledge that matches the scope of public health” (IOM, 1988). The following describes the progress schools of public health have made in implementing the IOM report recommendations.

Strengthening the link with public health practice. Fineberg and colleagues (1994) identify the 1988 IOM report’s insistence “that professional education be grounded in ‘real world’ public health” as the most influential recommendation in the report. This recommendation generated a number of initiatives aimed at establishing a closer relationship between schools of public health and public health practice. One of the first efforts following the IOM report was a collaborative study by the Johns Hopkins School of Hygiene and Public Health and the ASPH (funded by HRSA and CDC in 1989) to define the essential elements of the profession of public health. Public health practitioners and faculty from the schools of public health were brought together in the Public Health Faculty/Agency Forum, issuing a report in 1991 that emphasized:

public health education based upon universal competencies of public health practice; and

cooperation between schools of public health and public health agencies, including supervised practica for students (Fineberg et al., 1994).

The forum also recommended changing accreditation criteria to em-

phasize the practice of public health. In response, CEPH revised accreditation criteria to include a required practicum experience.

In 1991 the Council on Linkages Between Academia and Public Health Practice was established to “promote activities that link public health academic programs with the practice community through refining and implementing the forum recommendations” (Eisen et al., 1994). The Council, which includes representatives from national public health academic institutions and practice organizations, has initiated many efforts to enhance academic/practice collaboration. These include demonstration programs that examine academic/practice linkage approaches (Bialek, 2001), a national public health practice research agenda (Conrad, 2000), and a set of core competencies for public health professionals. The core competencies are organized around three job categories—front line staff, senior level staff, and supervisory management staff (Council on Linkages, 2001).

Schools of public health also have undertaken new initiatives to increase practice linkages. One of these is community-based participatory research, a research approach that involves all stakeholders in each aspect of a study designed to evaluate the application and impact of new discoveries aimed at improving the health of a defined population. This approach to research is discussed in greater detail in Chapter 3 . It requires active partnerships between the community and researchers who may or may not be members of that community. Partnerships and coalitions are important in developing prevention and health promotion programs or research today, because no single agency has the resources, access, and trust relationships to address the wide range of community determinants of public health problems (Green et al., 2001).

Other approaches to strengthening ties between schools of public health and public health practice were reported in a survey of schools of public health. The committee conducted a survey of schools of public health ( Appendix B ) that listed recommendations from The Future of Public Health (IOM, 1988) and asked schools to indicate what they had done in response. The survey was mailed by ASPH in February 2002 to all accredited schools. Of the then 31 accredited schools of public health, 25 responded to the survey, a response rate of 80.6 percent (see Table 2-1 for list of respondents).

One key recommendation in the 1988 report concerned linkages with state and local health departments, which are important to strengthening ties with the practice community. Each of the respondent schools indicated that at least some, and in some instances many, of their faculty have professional working relationships with state or local health departments or both. Their activities include conducting requested research projects, providing technical assistance, serving as the local epidemiologist or health officer, providing staff development or training, or serving on professional advisory committees. Major barriers to student involvement in

TABLE 2-1 Respondent Schools of Public Health ( n = 25)

Boston University

Emory University

Harvard University

Johns Hopkins

Ohio State University

Saint Louis University

San Diego State University

Texas A&M University

Tulane University

University of Alabama, Birmingham

University at Albany (SUNY)

University of California, Berkeley

University of California, Los Angeles

University of Iowa

University of Massachusetts

University of Medicine and Dentistry of

New Jersey

University of Michigan

University of Minnesota

University of North Carolina, Chapel Hill

University of Oklahoma

University of Pittsburgh

University of South Carolina

University of Texas, Houston

University of Washington

Yale University

activities with state and local health agencies were identified as lack of financial support and geographical distance from the health department.

The survey also asked about the importance of practice experience as criteria for admission of student applicants or in the faculty hiring process. For faculty recruitment, prior practice experience was rated very important or important by about one-third (32 percent) of the respondent schools while for student admission about one-half or 52 percent of schools rated prior experience very important or important.

Ties between schools of public health and the practice communities have been strengthened, but barriers remain. Foremost among the barriers is a lack of funding and incentives for such activities. As discussed earlier, schools of public health obtain most of their funding primarily through research grants and contracts, because federal support for teaching and practice activities has declined enormously during the past two decades and has not been replaced by state or private sources of funding. Additionally, the incentive and reward structure for faculty tenure and promotion is weighted heavily toward research and publication; teaching and practice activities carry comparatively little weight.

Another 1988 recommendation for linking schools to practice is for schools to participate in policy development. The survey asked schools to indicate how they fulfill their potential role as significant resources to government at all levels in the development of public health policy as well as barriers to engaging in this role. The vast majority of schools that responded have faculty who engage in numerous policy development activities as reflected in Table 2-2 .

New training opportunities. The Future of Public Health (IOM, 1988) recommended that schools of public health improve their educational approaches for the practicing public health workforce through short courses and continuing education. Currently, all accredited schools of public health

TABLE 2-2 Number and Percent of Schools Engaged in State Governmental Activities During the Past Five Years ( n = 25)

	Policy Development for Legislative Body	Public Health Advocacy with State Government	Public Health Advocacy with Local Government	Research Requested by State Policy-makers	Research Requested by Local Policy-makers	Public Health Workforce Development
Number	23	23	22	23	21	24
Percent	92	92	88	92	84	96

offer continuing education for public health professionals, as do the accredited programs. The overarching goal of continuing professional education is to educate and support public health professionals through enhancement of their knowledge and skills in public health practice, theory, research, and policy. Continuing education is an essential component of any career, according to Gordon and McFarlane (1996), and all schools and practice agencies should develop appropriate support systems for relevant continuing education for public health practitioners.

One approach to continuing education is to offer yearly conferences or workshops on specific topics. These programs can be sponsored by a college or university or in partnership with public health programs, agencies, or associations. They usually carry continuing education credits to meet the re-certification needs of the anticipated audience. Certificate programs are another approach to educating those currently working in public health. About one-third of the accredited schools of public health currently offer certificate programs. Standards for admission and completion vary across schools. Certificate programs may be general and emphasize core public health concepts from the five core content areas taught in M.P.H. programs, that is, epidemiology, biostatistics, environmental health sciences, health services administration, and social and behavioral sciences. Others focus on a specific content area such as international health, environmental health, occupational health, injury control, health policy, or health administration.

The CDC Graduate Certificate Program (GCP)—a program no longer funded—was a prime example of certificate programs. It was designed for CDC field officers, state health department personnel, and selected others with at least three to five years of experience in public health practice. The program allowed CDC Public Health Advisors working in state and local health departments to earn a graduate certificate in public health and was available from one of four accredited schools of public health: Tulane University School of Public Health and Tropical Medicine, Emory University Rollins School of Public Health, Johns Hopkins University

Bloomberg School of Public Health, and University of Washington School of Public Health and Community Medicine.

Academic institutions (including schools of public health) also offer summer institutes and courses. Subjects encompassed range from basic biostatistics, epidemiology, and Geographic Information Systems (GIS) applications, to management and administration for middle to senior managers. Such programs can vary in length from a single one-day course to week-long offerings. Another approach to traditional continuing education programs, as described by Halverson and colleagues (1997), involves the creation of masters- and doctoral-level executive programs that minimize time lost from work through use of distance learning teaching methods. By enabling workers to continue in their work responsibilities while completing self-paced coursework, this approach reduces the burden overworked and understaffed agencies feel as their staff members participate in educational programs.

The introduction of Web-based tools for education is producing a major change in the way schools and colleges conduct classes, particularly in the area of continuing education. The use of such technology is referred to as distance learning (Riegelman and Persily, 2001). This development builds upon more than two decades of computer networking activities (e.g., e-mail and bulletin board systems), and the increased availability of the Internet has produced phenomenal growth in the extent and scope of online education. Distance learning today has become an important alternative to traditional methods of education, because the existing technology has the potential to facilitate complicated distance learning environments and highly structured learning methods (Mattheos et al., 2001). The Public Health Training Network (PHTN) is an example of successful promotion of distance learning. This network has linked nearly one million people to training on a wide range of subjects in a variety of formats: print-based self-instruction, interactive multimedia, videotapes, two-way audio conferences, and interactive satellite videoconferences (CDC, 2001b).

Links with other departments and schools. The Future of Public Health (IOM, 1988) recommended that schools of public health develop new relationships with other schools and departments both within their universities as well as with other institutions of higher learning. Such collaboration is taking place, according to survey data. For example, 96 percent of reporting schools ( n = 24) indicated that their public health students could take courses in schools of medicine that would count toward their degree, as did 64 percent ( n = 16) for courses in nursing, 44 percent ( n = 11) in dentistry, 68 percent ( n = 17) in law, and 72 percent ( n = 18) in social work. Fifty-six percent ( n = 14) of responding schools

reported that students “often” avail themselves of these opportunities in other schools and departments and 28 percent responded “sometimes.”

Research. “[R]esearch in schools of public health should range from basic research in fields related to public health, through applied research and development, to program evaluation and implementation research” (IOM, 1988). To describe the range of research conducted in schools of public health the committee survey asked each school to estimate the percentage of research undertaken at the school that the respondent would characterize as:

basic or fundamental research, that is, research conducted for the purpose of advancing our knowledge;

applied research, that is, research designed to use the results of other research (e.g., basic research) to solve real world problems;

translational research, that is, research on approaches for translating results of other types of research to community use; or

evaluative research, that is, the use of scientific methods to assess the effectiveness of a program or initiative.

Among respondent schools the distribution of the types of research undertaken varied greatly. On average, applied research was reported most often (35 percent mean, range of 10–60 percent), followed by basic research (27 percent mean, range of 0–70 percent), evaluative research (20 percent mean, range of 1–50 percent), and translational research (17 percent mean, range 0–30 percent).

Broadening the scope of public health education. The 1988 IOM report recommended that schools of public health provide an opportunity to learn the entire range of skills and knowledge necessary for public health practice. Recent efforts to encompass a broad scope of education have focused on identifying basic competencies in public health and on developing curricula that teach the information and skills necessary to meet those competencies. The CDC Office of Workforce Policy and Planning (CDC, 2001c) has developed a table of public health competency sets ( Appendix F ). One of these is a set of core competencies developed by the Council on Linkages Between Academia and Public Health Practice (Council on Linkages, 2001). The ASPH has endorsed the Council on Linkages competencies and plans to develop complementary competencies for M.P.H. students.

One competency area relates to cultural competence. The committee survey of schools of public health requested respondents to indicate courses that they offer students in cultural or international health as well as other selected areas. Table 2-3 presents their responses.

TABLE 2-3 Number and Percent of Responding Schools Offerings Courses in Selected Areas ( n = 25)

	Cultural Competencies	Ethics	Health Disparities	Social Justice	Human Rights	International/ Global Health	Social Epidemiology
Number	16	22	19	17	13	18	15
Percent	64	88	76	68	52	72	60

The final question on the committee survey of schools of public health asked for input on identifying the most important challenges and opportunities facing schools of public health and M.P.H. programs over the next 10 years. The following summarizes responses to this question.

Survey responses identifying challenges and opportunities. According to respondents, public health as a profession is not well defined. Lack of clear definition is one reason the public does not understand the field. Raising public awareness of public health’s contributions to health and quality of life is important. Such awareness would help assure adequate support for public health programs. Lack of support and funding was a major issue identified frequently. Respondents indicated that increased funding is needed to support students and workforce development, and is critical to maintaining stable support for key academic programs including teaching. The major revenue source for schools of public health (i.e., external research funding) is seen as incongruent with the teaching mission and results in devaluing teaching and educational activities.

Respondents indicated that the changing environment and ever-widening scope of public health requires collaboration and partnerships with other disciplines. Additionally, within the field, schools need to build strong relationships among academia, scientists, and the professional practice community, thereby allowing each to benefit from the assets of the others.

Education and training issues were identified by numerous respondents. As one person wrote, “Public health is no different than other academic programs in that we tend to produce graduates for yesterday’s workplace and yesterday’s problems. Producing M.P.H. graduates responsive to what is needed today requires an understanding of the driving forces that affect public health practice and the public health workforce.” Respondents indicated that major needs include understanding that multiple factors influence health and that public health issues require societal change as well as changes in individual behavior for risk reduction. One respondent indicated that the primary goal of schools of public health should be to train the next generation of leaders as public health

scientists and public health professionals, stating that “Research informs practice and policy. Leadership guides them all.” The need for competencies in public health was mentioned several times. Other educational or training issues included:

Education at the M.P.H. level should be comprehensive, integrated, and broad-based to support the need for general public health preparedness, necessary for such things as bioterrorism preparedness.

M.P.H. programs need to be redesigned to permit greater flexibility in the development of clusters of skills and competencies in response to the rapidly changing public health environment.

Baccalaureate training in schools would provide a vehicle for attracting a new cadre of students into public health.

There is a need for opportunities for training in non-degree programs for part-time and mid-career students, and for increased distance learning programs.

There is a need for more practical experience for graduates.

Faculty issues were also addressed. Respondents indicated the need to recruit minority faculty to achieve diversity, that it was difficult to recruit faculty in specific disciplines such as biostatistics and epidemiology, and that it is necessary to maintain and improve faculty salary levels to be competitive with other sectors.

Another issue identified as important was building the public health infrastructure. Some respondents indicated that there should be national attention and standards for trained personnel, along with funding to meet those standards. Respondents indicated that schools should be expected to be a resource to provide training and to meet these standards and that a lack of standards and funding results in an inadequately prepared public health workforce. It was suggested that certification or credentialing of public health professionals is an important issue. One person suggested that certification might result in more uniform and rigorous programs to address core content needs. It was proposed that schools assist in the accreditation process for local departments of health by helping them meet their continuing education needs.

Respondents also indicated that the emphasis of public health research must be reviewed periodically. More prevention research is needed, including increased federal interest in prevention research. Schools of public health must more effectively promote prevention as a powerful means of health protection. Public health must find new approaches to reach the public on a level that effectively encourages primary prevention and enables individuals to change known risk behaviors to healthy behaviors. There should be increased emphasis on partnerships to develop viable

research programs. Understanding and addressing the determinants of ethnic and racial health disparities is an important research focus.

It was suggested that new monies flowing into public health for bioterrorism response should be used to help build the infrastructure. Finally, respondents identified, but did not elaborate on, the following challenges:

Globalizaation

Re-emerging infections

Human genome

Quality of health care

Un- and under-insured populations

Population aging

The establishment of the Johns Hopkins University School of Hygiene and Public Health in 1918 marked the beginning of public health education in a school dedicated to the field. There are currently 32 accredited schools of public health and 45 accredited community health programs. The Council on Education for Public Health estimates that the total number of accredited schools and programs may well double within the next 10 years and that the most dramatic growth is occurring outside the established schools of public health. Many of the nation’s accredited medical schools now have operational M.P.H. programs or are currently developing a graduate public health degree program (Evans, 2002). New specializations are emerging such as human genetics, management of clinical trials, and public health informatics. Many schools and competing organizations are involved in distance learning programs that offer the possibility of fulfilling the long-recognized need to bring public health education to the homes and offices of the public health workforce. The Internet also offers the possibility of bringing public health education to populations across the country and around the world; indeed, health information sites are among the most popular and frequently visited of all Web applications.

Previous efforts to design truly effective systems of public health education generally foundered because of a lack of political will, public disinterest, or a paucity of funds. Since September 11, 2001, however, the context has changed dramatically. With public health rising high on the national agenda and an abundance of funds being promised, perhaps there is now an opportunity, as there has not been for a very long time, to shape a future system of public health education that addresses the problems that have been so often described and analyzed.

Bioterrorism, drug—resistant disease, transmission of disease by global travel . . . there's no shortage of challenges facing America's public health officials. Men and women preparing to enter the field require state-of-the-art training to meet these increasing threats to the public health. But are the programs they rely on provide the high caliber professional training they require?

Who Will Keep the Public Healthy? provides an overview of the past, present, and future of public health education, assessing its readiness to provide the training and education needed to prepare men and women to face 21st century challenges. Advocating an ecological approach to public health, the Institute of Medicine examines the role of public health schools and degree—granting programs, medical schools, nursing schools, and government agencies, as well as other institutions that foster public health education and leadership. Specific recommendations address the content of public health education, qualifications for faculty, availability of supervised practice, opportunities for cross—disciplinary research and education, cooperation with government agencies, and government funding for education.

Eight areas of critical importance to public health education in the 21st century are examined in depth: informatics, genomics, communication, cultural competence, community-based participatory research, global health, policy and law, and public health ethics. The book also includes a discussion of the policy implications of its ecological framework.

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A Brief History of U.S. Foreign Aid

Where and why the United States gives foreign aid has changed over time. Learn the difference between military, economic, and humanitarian aid and the history behind U.S. aid.

A woman displaced by floods uses a box from the U.S. Agency for International Development to move her belongings in Dadu, Pakistan, on October 10, 2010.

Source: Akhtar Soomro/Reuters

According to opinion polls, many Americans believe about one quarter of the federal budget goes toward foreign aid . But the truth is foreign aid makes up less than 1 percent of the U.S. budget.

These overestimations may reflect a misunderstanding of foreign aid in general. For example, a 2013 survey found that, even though about half of Americans think the foreign aid budget should be cut back, as many as 82 percent support foreign aid when asked about its specific programs or goals.

So what is foreign aid?

Foreign aid is the money, services, or physical goods that a country sends to another to help it in some way. Foreign aid might support the recipient country’s economic growth, strengthen its social programs, respond to a crisis, or improve its defense capabilities. For example, during a health crisis, a country might send money to fund local hospitals, services in the form of doctors to administer medication, and goods in the form of those medicines themselves. (A country doesn’t need to be poor to receive aid—the United States regularly gives aid to countries with relatively high gross domestic products [GDPs] such as Israel.)

Foreign aid typically falls into four general categories:

Humanitarian aid

Humanitarian aid consists of materials or other forms of assistance for people in need due to manmade or natural disasters such as war, famine, and extreme weather. This type of aid often aims to address the immediate needs of a population in crisis.

Development aid

Development aid includes investments in the long-term economic development of a country or community. This type of aid aims to give people the building blocks to develop their own businesses and continued sources of income into the future.

Military aid

Military aid includes arms, training, money, or other forms of assistance for the explicit purpose of defense.

Political and economic aid

Political and economic aid supports political stability, economic policy reforms, and democratic institutions . It can provide general budget support in countries where the United States has strategic interests; it can also support activities such as peace talks, human rights organizing, political and criminal justice reforms, and treaty implementation.

The United States is the largest single provider of foreign aid worldwide in total dollars. Since World War II, the United States has distributed almost $4 trillion (adjusted for inflation ) in foreign aid. But most developed countries spend a higher percentage of their GDP on foreign aid than the United States does.

Almost half of U.S. foreign aid is coordinated through an independent government agency, the U.S. Agency for International Development (USAID). Depending on the project, about twenty other departments or agencies, such as the Department of Defense, Peace Corps, and economic development-focused Millennium Challenge Corporation, can be involved as well.

How does the United States use foreign aid?

The United States uses foreign aid as a foreign policy tool to further its interests abroad, while it also aims to promote democratic and humanitarian outcomes for the benefit of all people.

One belief that drives foreign aid is that investing in other countries creates a more stable, prosperous, and democratic world. In practice, multiple types of aid can be used to achieve this goal:

In 2020, the United States committed $4 billion in humanitarian assistance to an international partnership aiming to provide COVID-19 vaccines to ninety-two low- and middle-income countries.
In 2016, USAID focused on providing economic development aid to Bangladesh by partnering with local banks to give loans to low-income farmers to build their businesses.
In 2014, following years of accusations of election corruption in Georgia, USAID sent targeted political development aid to local organizations there to train and deploy election monitors.

Between 1946 and 2021, the United States has spent an average of $49.5 billion each year on foreign aid. Dozens of countries typically receive some form of U.S. foreign aid; a handful of them stand out as the biggest recipients: global counterterrorism partners, and countries with critical global health needs.

Does foreign aid work?

There is no simple answer to that question. Some experts note a lack of accountability for programs and places that receive aid to demonstrate effectiveness in achieving its goals; the accountability issue fuels criticisms that foreign aid is a waste of money. And in some cases, it’s difficult to determine whether foreign aid has achieved its goals: when, for example, the long-term goals include such things as sustainable development or a more peaceful world, measuring outcomes is difficult, especially in the short term.

Sometimes the effects of foreign aid can be more easily identified. As of 2022, the President’s Emergency Plan for AIDS Relief (PEPFAR) has delivered care to more than 25 million people and provided training for 340,000 health workers around the world (much of this progress was made in sub-Saharan Africa). (When the program launched in 2003, only fifty thousand people in Africa had access to any antiretroviral treatment.) Projects like PEPFAR that distribute humanitarian and development assistance demonstrably save lives and promote long lasting development.

But other programs are more of a mixed bag. Despite having received more than $100 billion in U.S. aid since 2002, several USAID projects in Afghanistan remain unfinished . When misused, foreign aid can perpetuate graft, reward mismanagement, and prop up authoritarians. The bottom line is that foreign aid can help but it can also be wasteful or even harmful.

What is true is that U.S. foreign aid has a far reach: economic and development aid that helped rebuild Europe after World War II, humanitarian aid in Africa, and more recently military and development aid to Afghanistan. Only a few places in the world haven’t felt the influence of U.S. aid in some way. The graphs below chart the ebb and flow of U.S. foreign aid into different countries and regions at different times. By looking at the aid flows in the context of what was happening in the world at the time, we can explore how the relationship between foreign aid and foreign policy priorities has evolved.

U.S. Foreign Aid to Regions Over the Years

Rebuilding Europe with the Marshall Plan: 1947–53 The modern era for U.S. foreign aid began after World War II, when the United States sent Western Europe one of the largest foreign aid packages in history. The Marshall Plan had two primary purposes: to rebuild Europe after the devastation caused by World War II and to prevent the Soviet Union , the United States’ main postwar rival, from spreading its communist ideology and influence in Western Europe. U.S. politicians thought that if European countries could avoid mass poverty as they rebuilt, their citizens would be less likely to launch a communist revolution. The Soviet Union and Eastern European countries in its orbit were offered the same aid package. But it was refused, with the Soviet Union condemning the program as U.S. interventionism. The Marshall Plan is especially significant because it influenced the national security focus of future U.S. foreign aid projects.

Defending Ukraine: 2022–Present Since Russia has launched a renewed and expanded invasion of Ukraine in 2022, the United States has been one of the top providers of security assistance to Ukraine. Since 2022, the United States has sent $76.8 billion to Ukraine in financial, humanitarian, and military aid. The aid sent to Ukraine marks the first time a European country holds the top spot of receiving U.S. aid since the Truman administration siphoned funds through the Marshall Plan.

Fighting Communism in the Vietnam War: 1946–77 The Vietnam War was waged from the mid-1950s to 1975 between communist North Vietnam, supported by China and the Soviet Union, and South Vietnam, supported by the United States. In the years leading up to and during the war, the U.S. government poured money into South Vietnam to support the military and promote stability. But following the North Vietnamese victory, the U.S. Congress severed diplomatic relations with and restricted most aid to the country. The United States only resumed providing aid when U.S.-Vietnamese relations began to normalize in the early 1990s. The United States also sent significant amounts of aid to South Korea and Taiwan during the Cold War . In South Korea, U.S. economic and military aid helped fend off a communist North Korea during the Korean War. It also helped jumpstart a dormant economy. In fact, some historians credit South Korea’s economic ascendancy in part to U.S. assistance. Similarly, U.S. aid to Taiwan in the 1950s and 1960s helped keep the government of communist China at bay. It also helped lay the foundation for the island’s economic growth.

Containing the Communist Threat in Latin America: 1961–68 After leftist revolutions sprang up in Latin American countries such as Cuba, stopping the spread of communism across the Western Hemisphere became an important U.S. goal. In 1961, President John F. Kennedy established the Alliance for Progress, an assistance program intended to relieve poverty and social inequality in the participating Latin American countries. Foreign aid spiked immediately after that. The goal was to apply the logic of the Marshall Plan to Latin America; economic stability would theoretically curtail the threat of revolution. The program was dissolved in 1973, largely due to a failure to address the social and economic issues it was meant to. Fighting a War on Drugs: 1982–2000s Starting in the 1980s, one of the priorities of U.S. foreign aid in Latin America was to stop the flow of illegal drugs into the United States. At the beginning of his first term, President Ronald Reagan declared a war on drugs both at home and abroad. Much of the United States’ cocaine supply came from Latin America. Any country in the region that the U.S. government determined was “doing its part” in the war on drugs would receive U.S. foreign aid. Colombia in particular received military aid and training in an attempt to reduce the quantity of drugs originating from the country. Although Colombia has seen some success in curtailing coca production, the UN Office on Drugs and Crime (UNODC) reported in 2017 that the country still accounted for an estimated 70 percent of the world’s cocaine supply.

Fighting AIDS in Africa: 2003–present Starting in the early 1990s, sub-Saharan Africa became the center of the HIV/AIDS pandemic . In 1999, HIV/AIDS was the leading cause of death across Africa. Even though testing and treatment for HIV/AIDS existed, they were not widely available in many African countries. After years of little global action, the United States established the President’s Emergency Plan for AIDS Relief (PEPFAR) in 2004 in select, mostly sub-Saharan African countries. The program allocated funding to provide medicine, money, and personnel to combat HIV/AIDS in affected countries because President George W. Bush believed extending humanitarian aid around the world was an important show of U.S. values. These values, he believed, would lead to more trust in American leadership. When PEPFAR launched, only fifty thousand people in Africa had access to any lifesaving antiretroviral treatment. As of December 2022, PEPFAR had provided that treatment to more than twenty-five million people around the world. PEPFAR quickly became the largest health initiative ever undertaken worldwide, and the U.S. government continues to contribute billions of dollars annually to its funding.

Establishing A Stronghold in the Middle East: 1976–present During the Cold War, when the United States and the Soviet Union were competing for global power and influence, the oil-rich Middle East rose in geopolitical importance to both countries. Several Arab states were aligning with the Soviet bloc, and the United States began to see its ally Israel as an important buffer against Soviet influence in the region. In part to bolster its ally, the United States provided Israel significant military aid during the Cold War. It also helped broker discussions that resulted in the 1979 Egyptian-Israeli peace treaty, after which it increased aid to Egypt. Even after the collapse of the Soviet Union in 1991, the United States saw Egypt and Israel as important promoters of regional stability. It continues to send billions of dollars in aid to both countries today. Fighting the War on Terror: 2003–present After al-Qaeda terrorists killed almost three thousand people in an attack on the United States on September 11, 2001, the United States declared a “war on terror” and invaded Afghanistan, which had provided sanctuary to the terrorists. Although the Iraqi government was not involved in the 9/11 attacks, the United States also invaded Iraq in 2003, in part on the incorrect assumption that the Iraqi government was developing weapons of mass destruction. After coalition forces toppled Iraqi leader Saddam Hussein and his government, U.S. troops fought insurgents and worked to support democratic institutions .

Fueling the Green Revolution: 1959–70 Because of a postcolonial focus on industrialization over agriculture, India was in the midst of a massive famine by 1961 as farmers were not producing enough food to feed the population. The United States sent foreign aid in the form of wheat to help alleviate the famine; in 1965, one-fifth of all U.S. wheat production went to India. USAID also helped fund agricultural development, including by helping to institute university programs that studied agriculture. This helped fuel what became known as the green revolution—the rapid development of new agricultural techniques that dramatically increased how much food countries could produce. Fighting the War on Terror: 2001–present After 9/11, the United States invaded Afghanistan and toppled its ruling group, the Taliban, which had been accused of hiding and protecting al-Qaeda operatives. What followed was two decades of aid packages aimed at creating some kind of stability in Afghanistan amid an active war, to mixed results. Although the United States withdrew in 2021, USAID programs continued to work to strengthen civil society, expand economic opportunity, and stabilize conflict zones in the country. The Taliban’s gaining of control of the country has further destabilized these efforts, raising new challenges.

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COVID-19 Vaccine: What You Need to Know

The COVID-19 vaccine is very good at preventing serious illness, hospitalization and death. Because the virus that causes COVID-19 continues to change, vaccines are updated to help fight the disease. It is important to check the Centers for Disease Control and Prevention (CDC) COVID-19 vaccine information for the latest details. (Posted 11/22/23)

What is the COVID-19 vaccine?

The COVID-19 vaccine lessens the severity of COVID-19 by teaching the immune system to recognize and fight the virus that causes the disease.

For fall/winter 2023–2024, the updated COVID-19 vaccine is based on the XBB.1.5 variant. The updated vaccine is made by Pfizer-BioNTech, Moderna and Novavax. This season, only one shot of the vaccine is needed for most people, and there are no boosters. (People who are immunocompromised or ages 6 months to 4 years may need more than one 2023–2024 vaccine.)

How is the 2023–2024 COVID-19 vaccine different from previous COVID-19 vaccines?

The 2023–2024 COVID-19 vaccine targets XBB.1.5, a subvariant of Omicron. While none of the variants currently circulating are exact matches to the vaccine, they are all closely related to the XBB.1.5 strain. Studies show that the updated vaccine is effective against the variants currently causing the majority of COVID-19 cases in the U.S.

Who should get a COVID-19 vaccine?

Because the 2023–2024 vaccine is effective for recent strains of COVID-19, it is recommended that everyone stay up to date with this vaccine. Previous vaccines or boosters were not developed to target the more recent strains. For 2023–2024, the CDC recommends:

Everyone age 5 and older receive one shot of the updated vaccine.
Children ages 6 months to 4 years may need more than one shot to be up to date.
People who are moderately or severely immunocompromised may need more than one shot.

You can review the full recommendations on the CDC’s Stay Up to Date with COVID-19 Vaccines webpage . Be sure to talk to your primary care doctor or pediatrician if you are unsure about vaccine recommendations.

What are the side effects of the COVID-19 vaccine?

Side effects vary and may last one to three days. Common side effects are:

Soreness at the injection site

COVID-19 Vaccine and Pregnancy

COVID-19 vaccines approved by the Food and Drug Administration (FDA) are safe and recommended for people who are pregnant or lactating, as well as for those r intending to become pregnant.

People who are pregnant or were recently pregnant are at a greater risk for severe COVID-19. Having a severe case of COVID-19 while pregnant is linked to a higher risk of pre-term birth and stillbirth and might increase the risk of other pregnancy complications.

What should parents know about the COVID-19 vaccine and children?

The CDC recommends the 2023–2024 vaccine for adolescents and teenagers ages 12 and older, and for children ages 6 months through 11 years.

Children age 5 and older need one shot of the updated vaccine.

Children are less likely to become seriously ill from COVID-19 than adults, although serious illness can happen. Speak with your pediatrician if you have questions about having your child vaccinated.

If I recently had COVID-19, do I need a 2023–2024 vaccine?

If you recently had COVID-19, the CDC recommends waiting about three months before getting this updated vaccine. If you encounter the virus again, having the updated vaccine will:

Lessen your risk of severe disease that could require hospitalization
Reduce the chance that you infect someone else with COVID-19
Help keep you protected from currently circulating COVID-19 variants

How long should I wait to get this vaccine if I recently had an earlier version of a COVID-19 vaccine or booster?

People age 5 years and older should wait at least two months after getting the last dose of any COVID-19 vaccine before receiving the 2023–2024 vaccine, according to CDC guidance .

Is natural immunity better than a vaccine?

Natural immunity is the antibody protection your body creates against a germ once you’ve been infected with it. Natural immunity to the virus that causes COVID-19 is no better than vaccine-acquired immunity, and it comes with far greater risks. Studies show that natural immunity to the virus weakens over time and does so faster than immunity provided by COVID-19 vaccination.

Do I need a COVID-19 booster?

The 2023–2024 vaccine is a one-shot vaccine for most people, and there is no booster this season. (People who are immunocompromised or ages 6 months to 4 years may need more than one 2023–2024 vaccine.)

The FDA calls this an updated vaccine (not a “booster” like previous shots) because it builds a new immune response to variants that are currently circulating. This change reflects the current approach of treating COVID-19 similarly to the flu, with preventive measures such as an annual vaccination.

When should I get a COVID-19 vaccine?

Like the flu and other respiratory diseases, COVID-19 tends to be more active in the fall and winter, so getting a vaccine in the fall is recommended.

How quickly does the COVID-19 vaccine become effective?

It usually takes about two weeks for the vaccine to become effective. The CDC website provides more information on how the COVID-19 vaccines work .

How long does the COVID-19 vaccine last?

Studies suggest that COVID-19 vaccines are most effective during the first three months after vaccination.

Is it safe to get a flu and COVID-19 vaccine at the same time?

Yes, it safe to get both shots at the same time. Keep in mind that each has similar side effects and you may experience side effects from both.

Is the COVID-19 vaccine safe?

Yes. COVID-19 vaccines approved by the FDA meet rigorous testing criteria and are safe and effective at preventing serious illness, hospitalization and death. Millions of people have received the vaccines, and the CDC continues to monitor their safety and effectiveness as well as rare adverse events.

Where can I get a COVID-19 vaccine?

The COVID-19 vaccine is available at pharmacies. See vaccines.gov to find a convenient location.

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